Design: A stepwise demonstration of the laparoscopic resection of the anterior abdominal wall endometrioma

Setting: A tertiary academic hospital with Minimally Invasive Gynecologic Surgery specialists

Patients or Participants: 39yo G3P3 with a history of endometriosis who presented for consultation for a right upper quadrant pain and a palpable mass.

Interventions: Abdominal wall endometriosis (AWE) is a type of extra-pelvic endometriosis found within the layers of the abdominal wall. The typical triad a patient presents with is cyclic abdominal pain, a palpable mass and history of abdominal surgery. 80-90% of AWE cases are associated with a surgical scar, with the most common being a Pfannenstiel incision. The standard of care for AWE is surgical excision. After our patient underwent consultation with appropriate imaging and counseling, she was consented for surgical intervention with diagnostic laparoscopy and resection of endometriosis.

Measurements and Main Results: A diagnostic laparoscopy was performed and utilizing palpation from above and visualization from below, the excision was strategically mapped out. An ultrasonic energy device was used to sharply resect the affected tissue. The cycle of palpating from above and dissecting laparoscopically was crucial throughout the case to ensure the entire specimen was removed. Following resection, a small defect in the fascia was noted, which was closed laparoscopically with suture passer device. The pathology was consistent with endometriosis.

Conclusion: AWE needs to be considered when patients present with cyclic abdominal pain, a palpable mass and a surgical history. Medical management can be considered for temporary symptom relief but will not reduce the size of the lesion. Surgical excision with 1cm margins is the standard of care for treatment of AWE. AWE involves the fascia in two-thirds of cases, which means a multidisciplinary surgical team will be necessary for fascial defects greater than 3cm if reconstruction or mesh is required.